RFP 24-037 Proposer Exhibits 1-5.pdf

Salem Area Mass Transit District (SAMTD) Healthcare Brokerage Services RFP 24-037

Exhibits 1 - 5 Page 1 of 7

TO BE SUBMITTED WITH PROPOSAL TO BE CONSIDERED RESPONSIVE

REQUIRED FORMS

SALEM AREA MASS TRANSIT DISTRICT

EXHIBITS #1 - 5

The following completed forms must be included in all quotes in order to be considered responsive in addition to the information requested in the Informal Request for Quotes document Part 3.C “Submission Package”.

Nonresponsive submissions will not be reviewed. Please sign and date each form and/or certification.

Exhibit #1 – Proposer Information Form

Exhibit #2 – Non-Collusion Affidavit

Exhibit #3 – Organizational Conflict of Interest

Exhibit #4 - Contractor’s Representations & Warranties Certification

Exhibit #5 – Price Proposal

Exhibits 1 - 5 Page 2 of 7

EXHIBIT #1 COMPANY INFORMATION FORM

The undersigned (“Proposer”), upon acceptance by SAMTD, agrees to furnish all labor, freight, transportation, materials, equipment, services, supplies, and other work in accordance with this Request for Proposal titled “Healthcare Brokerage Services”.

PROPOSER: The undersigned certifies as follows:

1. That he/she has read and understands all requirements and specifications of the Informal

RFQuotes (including all Appendices and any Addenda also posted); and

2. That he/she agrees to all requirements, specifications, terms, and conditions of the Informal

RFQuote referenced above; and

3. That he/she will furnish the designated item(s) and/or service(s) as quoted in the Informal RFQuote;

and

4. That he/she certifies under penalty of perjury that Proposer is, to the best of his/her knowledge, not in violation of any Oregon tax law; and

5. That his/her company has been certified as one (1) or more of the following registered business classifications:

DBE ______ MBE _______ WBE _______ ESB _______ Veteran-Owned _______

Corporation ______ Other, identify: ____________________________________

Resident Firm (Oregon): _____ Yes _____ No

6. Federal Tax I.D. Number: D&B (Dun’s) Number: _________________

Firm's Name:

Firm's Address:

Contact Person E-mail

Authorized Signature Date

Telephone Number Fax Number

Name of Project Manager and Title

7. Accounts Receivable Address, if different from above:

Exhibits 1 - 5 Page 3 of 7

8. Acknowledges receipt of the following addenda and understands failure to acknowledge

Addenda will render the Proposal nonresponsive:

Addendum No. Dated Addendum No. Dated

Proposer understands and agrees that, by his/her signature, if awarded the Contract for the project, he/she is entering into a contract with SAMTD that incorporates the terms and conditions of the entire Informal request for quotes package.

Proposer understands that this response constitutes a firm offer to SAMTD. If awarded the contract, Proposer agrees to deliver to SAMTD the required insurance certificates within ten (10) calendar days of the Notice of Award.

Proposer agrees to be bound by and will comply with the provisions of ORS 279C.838,279C.840 or 40 U.S.C.3141 to 3148.

IMPORTANT: This form must be signed below by the representative of the proposing firm, with authority to bind the Proposer to a Contract to authenticate the bid.

Authorized Signature: ______________________________ Date: _____________________

Printed Name: ________________________________________________________________

Title: ________________________________________________________________________

Exhibits 1 - 5 Page 4 of 7

EXHIBIT #2 NON-COLLUSION AFFIDAVIT

I state that I am (the sole owner) ____ (a partner) ____ (an officer) ____ (an agent) of ________________________, and that I am authorized to make this affidavit on behalf of my firm, and its owners, directors, and officers. I am the person responsible in my firm for the price(s) and the amount of this offer.

I state that:

1. The price(s) and amount of this offer have been arrived at independently and without consultation, communication, or agreement with any other contractor, Proposer, or potential Proposer.

2. That neither the price(s) nor the amount of this Proposal, and neither the approximate prices(s) nor approximate amount of this Proposal, have been disclosed to any other firm or person who is a Proposer or potential Proposer, and they will not be disclosed before the Proposal closing.

3. No attempt has been made or will be made to induce any firm or person to refrain from Proposing on this contract, or to submit a Proposal higher than this Proposal, or to submit any intentionally high or competitive Proposal or other form of complementary Proposal.

4. The Proposal of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other form of competitive Proposal

5. _______________________, its affiliates, subsidiaries, officers, directors, and employees are not currently under investigation by any governmental agency and have not in the last four (4) years been convicted of or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to Proposing on any public contract.

I state that ______________ understands and acknowledges that the above representations are material and important, and will be relied on by Salem Area Mass Transit District in awarding the contract(s) for which this Bid is submitted. I understand and my firm understands that any misstatement in this affidavit is and shall be treated as fraudulent concealment from Salem Area Mass Transit District of the true facts relating to the submission of Bids for this contract.

Signed: ________________________________________ Date: ______________________

Printed Name and Title ________________________________________________________

Exhibits 1 - 5 Page 5 of 7

EXHIBIT #3 ORGANIZATIONAL CONFLICT OF INTEREST

AND AVOIDANCE / MITIGATION PLAN

This disclosure statement outlines potential organizational conflicts of interest, either real or apparent, which as a result of activities or relationships with other persons or entities, such person or entity:

1. Is unable or potentially unable to render impartial assistance or advice to Salem Area Mass Transit

District; or

2. Is or might be otherwise impaired in its objectivity in performing the contract work; or

3. Has an unfair competitive advantage.

SECTION I. List potential organizational conflicts of interest. An organizational conflict of interest exists where other activities, relationships, or contracts of a contractor inhibit, affect, or prevent the contractor from rendering impartial assistance or advice to SAMTD; a contractor's objectivity in performing the contract work is or might be otherwise impaired (e.g., a contractor assisting with a design might have a financial interest in a product or system that could be utilized in implementing that design); or a contractor has an unfair competitive advantage which might be gained through its involvement in writing, or reviewing the solicitation and contract documents, including the scope or specification except as part of a general industry review.

SECTION II of this disclosure statement describes the management plan for avoiding or neutralizing the potential Organizational Conflicts of Interest as described in SECTION I of this disclosure statement. I acknowledge that Salem Area Mass Transit District may require revisions to the management plan described in SECTION II of this disclosure statement prior to approving it, and that Salem Area Mass Transit District has the right, in its sole discretion, to limit or prohibit my involvement in the Project as a result of the potential conflicts of interest described in SECTION I of this disclosure statement.

SECTION Ia – Name of Person or Firm Potentially Conflicted

SECTION Ib – Current Project Name and Scope of Work

SECTION Ic – Future Project Name and Description of Potential Conflict of Interest

SECTION II - Plan for Managing Potential Conflicts of Interest

Signed _____________________________________ Date __________________________

Printed Name and Title ________________________________________________________

Exhibits 1 - 5 Page 6 of 7

EXHIBIT #4

CONTRACTOR’S REPRESENTATIONS AND WARRANTIES

CERTIFICATION

(State of Oregon)

Contractor hereby represents and warrants to Salem Area Mass Transit District (SAMTD) that:

1. Contractor has the power and authority to enter into and perform this Contract.

2. This Contract, when executed and delivered, is a valid and binding obligation of

Contractor, enforceable in accordance with its terms.

3. Contractor (to the best of Contractor’s knowledge, after due inquiry) has never knowingly or intentionally failed to comply with:

(i) All tax laws of this state, including but not limited to ORS 305.620 and ORS

Chapters 316, 317, and 318;

(ii) Any tax provisions imposed by a political subdivision of this state that applied to

Contractor, to Contractor’s property, operations, receipts, or income, or to Contractor’s performance of or compensation for any work performed by Contractor;

(iii) Any tax provisions imposed by a political subdivision of this state that applied to

Contractor, or to goods, services, or property, whether tangible or intangible, provided by Contractor; and

(iv) Any rules, regulations, charter provisions, or ordinances that implemented or enforced any of the foregoing tax laws or provisions.

4. Any goods and/or services to be provided to SAMTD, in the performance of Contractor’s obligations under this Contract, shall be provided to SAMTD free and clear of any and all restrictions on or conditions of use, transfer, modification, or assignment, and shall be free and clear of any and all liens, claims, mortgages, security interests, liabilities, charges, and encumbrances of any kind.

Contractor Name: _____________________________________________________________

Signature of Authorized Representative: ___________________________________________

Printed Name: _______________________________________Date: ____________________

Title/Position: _________________________________________________________________

Exhibits 1 - 5 Page 7 of 7

EXHIBIT #5 PROPOSAL PRICE FORM

Instructions: Please complete this form to provide your proposed price for the services listed in the Scope of Work, RFP Part 2. The Total Contract Price offered shall include any and all costs and charges necessary to accommodate the requirements of the Contract. Contractor will be paid only for work actually performed. Do not include travel

Broker Services Year 1 $_______________

Broker Services Year 2 $_______________

Broker Services Year 3 $_______________

Broker Services Year 4 $_______________

Broker Services Year 5 $_______________

Total 5 – Year cost $ __________________

Proposer understands and agrees that, by his/her signature, if awarded the contract for the project, he/she is entering into a contract with SAMTD that incorporates the terms and conditions of the entire Request for Proposal package.

The person signing this Price Proposal in response to the RFP certifies that he/she is authorized by the Proposer to sign on the Proposer's behalf, and that the Proposer shall be bound contractually by that signature.

The documents enclosed with this Proposal shall be made a part of the contract if the contract is awarded to this Proposer. This Proposal is made without connection with any other person, firm, or corporation making a Proposal for the same contract, and is in all respects fair and without collusion or fraud.

Contractor Name Federal ID

Signature of Authorized Representative Date:

Printed Name

Title